Category: Dr. Smith’s ECG Blog

Written by Pendell Meyers with edits by Steve Smith I was sent these 2 ECGs with no clinical information other than chest pain: Do either or both of these ECGs show ischemic changes? If so, what should you do and why? Let’s take them one at a time. What would your response be? I responded:

A 60-something presented with hypotension, bradycardia, chest pain and back pain. She had a h/o aortic aneurysm, aortic insufficiency, peripheral vascular disease, and hypertension. She had a mechanical aortic valve. She was on anti-hypertensives including atenolol, and on coumadin, with an INR of 2.3. She was ill appearing. BP was 70/49, pulse 60. A bedside

A 50-something presented with epigastric and chest pain. Here is his ECG: What do you think? QTc 388 ms. Computer interpretation: SINUS RHYTHMINCOMPLETE RIGHT BUNDLE BRANCH BLOCKST ELEVATION, CONSIDER SEPTAL INJURY***ACUTE MI*** There is a saddleback, which is rarely due to MI. V2 has the morphology of type II Brugada, as there is a relatively large

Written by Pendell Meyers with edits by Steve Smith A male in his 60s presented with off and on shortness of breath and chest pressure over the past few days. He was hypertensive and tachycardic, with mildly increased work of breathing. Here is his initial ECG: What do you think? What will you do for

An elderly woman presented with 25 minutes of chest pain after working out. This ECG was texted to me and I viewed it on my phone hurriedly during a meeting: There was an old ECG with it: What do you think? The sender wrote: “I’m thinking proximal LAD or LM. Your thoughts?” I wrote: “Agree

I posted this one on October 9, but it was buried in a discussion of a paper on triage ECGs: Another Inadequate Paper Published on Triage ECGs, whose Conclusions Need Scrutiny. I wanted to put it out there on its own: These are diagnostic hyperacute T-waves.You can see the computer interpretation above.This patient had an

Written by Pendell Meyers, case submitted by Max Macbarb, edits by Steve Smith A 71 year old gentleman with history of CAD and PCI presented with acute chest pain and normal vitals signs. He was triaged to the general area of the emergency department after an initial review of this ECG by a senior resident

This patient called 911 for chest pain. The medics did an amazing job of recording serial ECGs. Time zero Hyperacute T-wave and subtle STE in aVL with Reciprocal ST depression (with reciprocally hyperacute T-waves!) in inferior leads.ST depression in V3-V6 typical of diffuse subendocardial ischemia. High lateral STEMI [typical of circumflex or first diagonal (D1) occlusion]?

Written by Pendell Meyers I received two texts recently, in both cases the practitioners were worried about possible inferior hyperacute T-waves with an inverted T-wave in aVL. I was not given any clinical history. What would you tell the team in these two cases? Case 1 Case 2 My responses: Case 1: “Not hyperacute. The